Guidance and Standard Operating Procedure

COVID-19 Virus Testing in NHS Laboratories

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1. 0 Background
• In December 2019, a novel coronavirus (COVID -19) caused an outbreak in
Wuhan, China, and soon spread to other parts of the world. It is believed that
COVID-19 is transmitted through the respiratory tract and can induce
pneumonia.
• The ongoing outbreak poses a challenge for public health laboratories as the
outbreak is widespread and international spread through travellers is now
evident as is spread from affected individuals.

• The priority to facilitate public health testing was undertaken by Public Health
England (PHE) at the Colindale facility and their regional laboratories.
• The preferred screening/testing is by Molecular diagnosis of COVID-19 by
real-time RT-PCR (RdRp gene assay) based on oral swabs, which has been
used for confirmation of this disease by PHE laboratories.
• PHE has been working closely with NHS England and Improvement (NHS E
and I) Pathology Network Laboratories to increase capacity of testing, which
is now needed to continue to identify and maintain the required containment
of affected individuals and delay and mitigation of spread.
• As part of the escalation and management of this viral infectious outbreak, a
Phased approach to onboarding NHS E and I Pathology Network
Laboratories, across England, is being undertaken, working closely with PHE,
so that patients and NHS E and I Staff can receive timely testing, intervention
and treatment.

2.0 Aims and Objectives

• This document provides guidance and the standard operating procedure
(SOP) for COVID-19 testing for NHS E and I Pathology Network Laboratories.
This document will also provide information on the communication routes and
information flows that support the management of return of patient results.
• This guidance and SOP has been developed with PHE and NHSE and I
working in partnership.
• The aim is to deploy robust diagnostic methodology for use in all laboratory
settings using accepted validation and verification protocols with positive
control virus material available from Colindale PHE laboratory as part of the
capability and assurance framework.

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3.0 Scope
• This SOP covers COVID-19 testing to be deployed by NHS E and I Pathology
Networks

• This SOP does not cover the investigation and testing of other respiratory
infections not caused by COVID -19.

4.0 Overview
Public Health England (PHE) have been undertaking all formal testing for COVID-19
and now have an established service in all regional PHE and some NHS E
designated testing laboratories (mainly in London).
This initial capacity now needs to be supported and increased using NHS
laboratories with appropriate facilities, and with some initial support from PHE.
This guidance outlines the requirements for a designated NHS Laboratory to deliver
a COVID-19 testing service using their preferred testing protocols and processes.
This guidance also specifies the type of specimens that will be tested and other
regulatory requirements.
Due to the nature and need to establish greater testing capability we are asking each
pathology network to identify a hub laboratory to lead on this work, with the stated
aim to provide a minimum capacity of 500 tests per day for COVID-19 testing in
the NHS. This activity is in addition to existing capacity that may be available in the
network via existing PHE testing laboratories.
Laboratories must consider how these services can be provided 7 days per week
and clearly identify any potential bottle necks in the testing pathway that may restrict
processing capacity. This may include, availability of staff, other assays that use the
equipment that may restrict capacity, containment facilities – taking note of the HSE
requirements (Appendix 9) and any logistics and supply chain issues.
It is expected that the nominated NHS Laboratories will be mobilised rapidly to
undertake local testing of individuals for COVID-19, in whichever locality they may
arise in England. All the participating microbiology/virology labs will be UKAS 15189
accredited and have an accredited quality management system. Although they may
have similar tests/technologies within the scope of their accreditation, it is likely that
the introduction of testing for COVID-19 will not be included in this accreditation.
However, there are stringent requirements to demonstrate assay performance using
accepted validation and acceptance criteria, which will mitigate in part this
requirement, and NHS Laboratories will need to assure that they have undertaken
this using internal and external Quality Assurance (QA), before offering this testing
service to patients. In the meantime, NHSE and I is working with UKAS to explore
how urgent extensions to scope could be introduced.

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In addition, PHE have been working with the Health and Safety Executive (HSE) to
establish the appropriate level of containment for sample handling and processing
(see PHE guidance in Appendix 9). All Laboratories undertaking testing will need to
complete their own Risk Assessments, guidance can be found at Appendix 9.
This document is not designed to replicate, duplicate, or supersede any relevant
PHE guidance or other guidance (see Appendix 1) or legislative provisions which
may apply. In the event of new guidance emerging, this guidance will be reviewed
and amended with as much rapidity as possible.

5.0 Testing Standard Operating Procedure

5.1 Background

Due to the need to establish greater testing capability NHS E and I are asking
identified pathology network laboratories to commence working up validation of
commercially available kits that can be automated to further increase the available
testing capacity across England. Due to the public health requirement for this action
to be taken at pace we do not expect these assays to be provided in scope, initially,
in terms of UKAS ISO 15189 accreditation, however, it is expected that an in-house
validation to demonstrate the acceptance of these assays has been performed.
Commercial kits should be CE marked and any in-house assay must meet locally
agreed acceptance criteria prior to patient use.
Once the test is validated, and Risk Assessments have been completed, (see
Appendix 9) a 24/7 offering should be considered, and testing should be prioritised
above other Pathology Tests as Urgent and High Priority including the return of
results.

Samples that are positive on testing by the NHS Pathology Network Laboratories
can be considered as presumptive positives, initially, if confirmation is required to be
carried out by a local Public Health England (PHE) Laboratory (See list – Appendix
2). Although this is not required if Network Laboratories are confident in the test they
have adopted and assured of an accurate result. If in any doubt, samples can be
referred to a Public Health England (PHE) Regional Laboratory local to the NHS
Testing Laboratory, for confirmatory testing, for an initial period, until the NHS
Network Laboratory is assured their testing is robust, accurate and safe, after which
time confirmation by Local PHE Laboratories will no longer be required. Any Positive
results that are sent for confirmation to a PHE Laboratory, will be considered
Presumptive Positives until confirmed. Presumptive Positive/Positive results will be
notified to the coordination center for contact tracing, which will commence
immediately.

Please note that patients who are admitted to hospital will need additional respiratory
samples taken for testing for other respiratory pathogens, such as influenza, in
addition to those detailed below for COVID-19. These additional tests must be
carried out by the local referring laboratory – other samples must not be forwarded to
the designated PHE regional or NHS E and I laboratory that will be carrying out the

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COVID -19 screening test, unless this is the same laboratory, i.e. routine practice
must be followed for other tests.

If testing for avian influenza is also indicated (based on assessment of travel and
exposure histories), specific and separate samples will need to be collected and sent
to the appropriate laboratory as per routine practice.

If testing for MERS-CoV is also indicated (based on assessment of travel and

exposure histories), specific and separate samples will need to be collected and sent
to the relevant laboratory as per routine practice.

Where Ct values are below an agreed value (based on analysis of Proficiency

Testing performance and other local testing data) with satisfactory quality control
parameters including internal control performance, the result is considered valid and
should be telephoned and a report issued as a final result. Any such positive result
will be recorded as “confirmed” for Public Health reporting purposes and will be
notifiable under recent legislation.

Results where:
• the Ct value is => 40, AND/OR
• there is an abnormal assay curve, AND/OR
• the clinical context makes the positive result highly unexpected

should be considered interim or held until reviewed by a laboratory clinician.

Laboratories will undertake the following actions:
• defer telephoning of the uncertain result to the clinician looking after the
patient (or telephoning it with clear caveat regarding the uncertainty)
• re-extract the original sample and repeat the PCR in the original and new
ex-tract in duplicate
• perform testing on a further respiratory sample (or samples) from the same
patient
• confirm with an alternative, equivalent sensitivity assay locally or where
none is available, they should forward the sample to Colindale
• Regular review of expected performance of reagents, particularly control
materials

The actions taken should be expedited in order to minimise the delay in obtaining a
definitive result for the patient. Only confirmed results are expected to be notified to
public health and other stakeholders.
A fully validated protocol for N gene detection, which is of equivalent sensitivity to
RDRP assay, is available for immediate implementation as an additional assay

Ambiguous samples for referral to Colindale for further characterisation

(genomics/virus isolation/phenotypic work):

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 • Deaths, and/or other very severe clinical cases
• Unusual samples which cannot be resolved locally
• Unexpected findings eg cases associated with neurological features
• As required for surveillance purposes, as schemes are developed.

Further instructions will be provided as these are developed.

5.2. Explanation of sample sets

5.2.1 Samples required for initial diagnostic testing (possible case)

1. Upper respiratory tract sample(s): combined viral nose and throat swab, or a
viral nose swab and a viral throat swab combined into one pot of viral
transport medium, or a single swab used for throat then nose, or a
nasopharyngeal aspirate in a universal transport pot.
2. Lower respiratory tract sample (sputum) if obtainable, in a universal container

Additionally, if the patient is admitted to hospital, take a sample for acute serology.

• 5mL serum tube or plain (no additive) tube; for children <12 years, 1mL is
acceptable.

Important points about sample-labelling and request forms include:

• label each sample with ID, date of birth and type of sample
• use the specific form for requesting COVID-19 acute respiratory disease
testing (E28), one form for each sample
• do not place paperwork (request forms) in the primary container for Category
B transport
• request form must include a contact phone number for sharing of results and
a contact number for the patient
• samples without appropriate paperwork will not be tested or testing will be
delayed

See Appendix 6 for Sampling and Packaging Poster.

5.2.2. Samples required for monitoring confirmed COVID-19 acute respiratory

disease

Sequential sampling may be required to monitor the progress of confirmed COVID-

19 acute respiratory disease, decided on a case-by-case basis.

5.2.3. Sending samples to the testing laboratory

The referring laboratory must send the sample to the designated pathology network
laboratory listed in how to arrange laboratory testing. There is no need to call the
local testing laboratory or HPT or PHE regional laboratory to request testing.

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All samples for COVID-19 testing should be packaged and transported in
accordance with Category B transportation regulations and labelled ‘Priority 10’. UN
3373 packaging must be used for sample transport.

Further guidance is given on packaging and transport of samples in safe handling

and processing for laboratories. PHE follows the World Health Organization (WHO)
guidance on regulations for the transport of infectious substances 2019-2020, NHS E
and I Laboratories are advised to do the same.

If the referring laboratory needs to know whether the samples have arrived at the
designated laboratory, they should contact the courier for tracking information.

5.3 Testing protocols for COVID -19

The PHE testing protocol, if NHS Laboratories are NOT adopting CE Marked
commercial assays, can be found at Appendix 5. This protocol describes a uniplex
real-time RT-PCR assay for the detection of the 2019 novel coronavirus (2019-
nCoV).

NHS E Laboratories can choose to process samples on the laboratory’s chosen

platform and protocol, please see recommended list that appears in section 5.4
below. (This will be updated as other systems, devices and protocols become
available). NHS E Laboratories will need to show local validation and verification
of testing, before providing these services, which must include internal and external
QA.
In addition, local Risk Assessment will need to be carried out by every
Laboratory as part of the HSE requirement for testing, see Appendix 9.

5.4 Systems under evaluation for COVID testing

The current Systems (as of 06/03/2020) under evaluation can be found at Appendix
8.

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 Current COVID
5.5 Notification of Presumptive -19
Positive/ Testing
Positive workflows
Results and Negative Results

Test Result Negative

EXCEL SPREAD SHEET

Reporting Results
Result entered on Testing Laboratory database
(?eLAB, NPEX, StarLIMS)

Local Laboratory Clinician Responsible1 will pass

test results to ‘Regional Test and Result Service’
who will Contact Patient with Result

++ve

Patient can Self

Isolate for 14 days
Clinician Responsible1 Clinician Responsible1
1
Clinician Responsible Notifies To Confirm All Their Also to Ensure ‘, PHE,
‘Regional Test and Result Patients and Results COVID ID Network HPT
Service’, PHE, COVID ID have been to RTRS and EPRR informed of
Network, HPT and EPRR. Result

RTRS Notifies the

CMS

1. The clinician responsible may devolve the work to another clinician but must maintain accountability for patient
being done.
2. To note: Regional Test and Result Service is provided by ambulance services as part of the Regional Incident
Coordination Centre

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6.0 Information Flows
6.1 Information Flows
Electronic requesting and reporting should be the accepted standard. All laboratories
referring and receiving requests should seek to automate this process. Many
laboratories are linked via the NPEx or similar. These links should be used if
available. Laboratories should seek to ensure transmission of results via Text is
possible.
Positive results can be confirmed by PHE Regional Laboratories until the NHS E
Testing Laboratory is confident of their testing, the Testing Laboratory will need to
liaise with their local PHE Laboratory and send sample(s) for confirmatory testing, if
confirmation of results is needed, this also applies for ambiguous results. See link
below for further guidance.
https://www.gov.uk/government/publications/wuhan-novel-coronavirus-guidance-for-clinical-
diagnostic-laboratories/laboratory-investigations-and-sample-requirements-for-diagnosing-and-
monitoring-wn-cov-infection

Presumptive Positive/Positive results will be reported back to patients by Testing

Laboratory or Clinician Responsible at Referring Laboratory, according to flow
diagram above, within 48 hours, and confirmed if local PHE lab has undertaken
confirmatory testing. Confirmed results will be reported back to patients within 72
hours of presumptive positive test results, if PHE Lab confirmation has been
requested.
All negative results will be reported back to the clinician responsible* for patient
sampling, who will have responsibility for ensuring patients are informed. This is
currently envisaged to be via the route that results are normally communicated to the
requesting clinician for onward communication to the patient. We are currently
reviewing this with DHSC and NHS Digital. The diagram in section 5.5 above,
outlines the current expected practice. Some centres are using SMS messaging via
their electronic patient record to pass on negative results directly to patients. Where
possible these options should be explored.

7.0 Additional Support

7.1 From PHE
PHE will provided expert support through dedicated experts who can be contacted to
address any technical or clinical issues, Laboratories seeking such support will need
to make all requests via nhsi.pathemergencyresponse@nhs.net.
7.2 From NHS E and I
NHS E and I has a dedicated Laboratories and Specialised Services Shortage
Response Group (LSS SRG) for Pathology that can be contacted at this email
(nhsi.pathemergencyresponse@nhs.net ), who will be able to provide support in the

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event of supplies shortages, advice on resilience and business continuity (See
Appendix 4).

8.0 Further Information

8.1 Further information can be found in the annexes in the following sections:
− Appendix 1: Other relevant guidance
− Appendix 2: List of PHE Laboratories
− Appendix 3: List of NHS E and I Pathology Network Laboratories in
Phase 1 roll out.
− Appendix 4: LSS SRG – Pathology Central Contact Email
− Appendix 5: PHE COVID-19 Testing Protocol
− Appendix 6: Sampling and Packaging Poster – PHE Guidance
− Appendix 7: PHE Presumptive Positive Testing Request Form
− Appendix 8:Testing Systems Under Evaluation by PHE (As of
06/03/2020)
− Appendix 9: Health and Safety Guidance

For any queries please contact:

nhsi.pathemergencyresponse@nhs.net

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Appendices
Appendix 1: Public Health England and other Guidance

• Public Health England (PHE) 2020 ‘Guidance - Wuhan novel coronavirus:

epidemiology, virology and clinical features’ (Updated 27 January 2020)
https://www.gov.uk/government/publications/wuhan-novel-coronavirus-
background-information/wuhan-novel-coronavirus-epidemiology-virology-and-
clinical-features
• Public Health England (PHE) 2020 ‘Guidance - Wuhan novel coronavirus:
infection prevention and control’ (updated 15 January 2020)
https://www.gov.uk/government/publications/wuhan-novel-coronavirus-
infection-prevention-and-control
• Public Health England (PHE) 2020 ‘Laboratory investigations and sample
requirements for diagnosing and monitoring WN-CoV infection - Guidance
(Updated 27 January 2020)
https://www.gov.uk/government/publications/wuhan-novel-coronavirus-
guidance-for-clinical-diagnostic-laboratories/laboratory-investigations-and-
sample-requirements-for-diagnosing-and-monitoring-wn-cov-infection

• Public Health England (PHE) 2020 ‘Guidance - Wuhan novel coronavirus:

guidance for clinical diagnostic laboratories’ (Updated 27 January 2020)
https://www.gov.uk/government/publications/wuhan-novel-coronavirus-
guidance-for-clinical-diagnostic-laboratories

• Public Health England (PHE) 2020 ‘Public Health England (PHE) 2020 ‘WN-
CoV: Laboratory Investigations and Sample Requirements (Version 1.0, 17
January 2020)’
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/
attachment_data/file/859086/Laboratory_investigations_algorithm_WN-
CoV_v1_17_Jan.pdf

• World Health Organization’s (WHO) (2019) ‘Guidance on regulations for the

transport of infectious substances 2019–2020’
https://www.who.int/ihr/publications/WHO-WHE-CPI-2019.20/en/ (1 January
2019)

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 • World Health Organization’s (WHO) (2020) ‘Global Surveillance for human
infection with novel coronavirus (2019-nCoV) - Interim guidance’ (20 January
2020)
https://www.who.int/publications-detail/global-surveillance-for-human-
infection-with-novel-coronavirus-(2019-ncov)
• World Health Organization’s (WHO) (2020) ‘Surveillance case definitions for
human infection with novel coronavirus (nCoV)’ (10 January 2020)
https://www.who.int/publications-detail/surveillance-case-definitions-for-
human-infection-with-novel-coronavirus-(ncov)

• World Health Organization’s (WHO) (2020) ‘Household transmission

investigation protocol for 2019-novel coronavirus (2019-nCoV) infection -
Interim guidance’ (25 January 2020) https://www.who.int/publications-
detail/household-transmission-investigation-protocol-for-2019-novel-
coronavirus-(2019-ncov)-infection

• World Health Organization’s (WHO) (2020) ‘Infection prevention and control

during health care when novel coronavirus (nCoV) infection is suspected -
Interim guidance’ (25 January 2020)
https://www.who.int/publications-detail/infection-prevention-and-control-
during-health-care-when-novel-coronavirus-(ncov)-infection-is-suspected-
20200125

• World Health Organization’s (WHO) (2020) ‘Laboratory testing for 2019 novel
coronavirus (2019-nCoV) in suspected human cases - Interim guidance’ (17
January 2020) https://www.who.int/publications-detail/laboratory-testing-for-
2019-novel-coronavirus-in-suspected-human-cases-20200117

Note: This list is not exhaustive and is rapidly evolving. The Provider will be
expected to respond to new and emerging guidance.

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Appendix 2: PHE Laboratories

NHS Designated Address for sample Contact telephone

Region laboratory dispatch numbers

Normal hours Out of hours

Public Health England,

Public Health Laboratory,
Box 236, Cambridge
East of Cambridge University Hospitals NHS 01223 245151 (Ask for
01223 257037
England PHL Foundation Trust, on call Virologist)
Cambridge Biomedical
Campus Hills Road,
Cambridge, CB2 0QQ

Respiratory virus unit

Respiratory (RVU), Public Health
020 8200 4400 (Ask for
London virus unit, England, 61 Colindale 0208 327 7887
Duty Doctor)
Colindale Avenue, London, NW9
5EQ

Public Health Laboratory

Birmingham, Birmingham
Birmingham 0121 4242000 (ask for
Midlands Heartlands Hospital, 0121 424 3111
PHL duty virologist)
Bordesley Green East,
Birmingham, B9 5SS

0191 233 6161

Molecular Diagnostics 0191 233 6161
(Newcastle upon Tyne
Laboratory, Microbiology (Newcastle upon
Hospitals NHS
North and Virology Department, Tyne Hospitals NHS
Newcastle lab Foundation Trust,
East Freeman Hospital, Foundation Trust,
switchboard) Ask for
Newcastle upon Tyne, NE7 switchboard) Ask for
on-call Consultant
7DN Consultant Virologist
Virologist

Virology Reception, Third

North Manchester Floor, Clinical Science 0161 276 1234 (Ask for
0161 276 8853
West PHL Building 1, Oxford Road, on-call Microbiologist)
Manchester, M13 9WL

Microbiology, Level B,
023 8077 7222 (ask for
South Laboratory block,
South Southampton out of hours
Southampton General 023 8120 6408
East lab Microbiology
Hospital, Tremona road,
biomedical scientist)
Southampton SO16 6YD

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 NHS Designated Address for sample Contact telephone
Region laboratory dispatch numbers

PHE Microbiology, Public

Health England, Pathology 0117 950 5050 (Ask for
South
Bristol PHL Sciences Building, 0117 414 6222 on-call Virologist or
West
Westbury, Bristol, BS10 Microbiologist)
5NB

0113 392 8750 0113 243 2799 or 0113

Virology Department, Old
(option 2) (Leeds 243 3144(Leeds
Yorkshire Medical School, Leeds
Teaching Hospitals Teaching Hospitals
and Leeds lab General Infirmary,
Trust, switchboard) Trust, switchboard) Ask
Humber Thoresby Place, Leeds LS1
Ask for on-call for on-call Consultant
3EX
Consultant Virologist Virologist

Appendix 3: List of Phase 1 NHS E and I Laboratories already undertaking COVID-

19 testing -
Guys and St Thomas’s Hospitals
Health Services Laboratories (HSL - UCLH, RFH, The Doctors Laboratory)
Kings College Hospital
St Bart’s Hospital

Appendix 4: LSS SRG – Pathology Central Contact

Email: nhsi.pathemergencyresponse@nhs.net

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Appendix 5: PHE COVID -19 Testing Protocol – If not using Commercial Assay

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Appendix 6

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Appendix 7: Presumptive Testing Request Form

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 Appendix 8: Testing Systems under evaluation as of 06/03/2020
Other equip
Supplier PCR platform required required? DNA extraction
PCR set-up on board
AusDiagnostics Proprietary workstation / platform platform off board
No, but their 'NIMBUS'
unit can do extraction off board or on
Seegene-Mast BioRad CFX and PCR set-up NIMBUS
Roche MagNa Pure or
Roche - TiB molbio - Roche LightCycler 480, 480 II or cobas z480 other product
Manchester evaluation (open channel) no manufacturers
Mx3005P (Stratagene), VERSANT (Siemens),
ABI7500 SDS (AppliedBiosystems), Rotorgene
6000 or Q5/6 (Qiagen), CFX96 (BioRad),
Altona LightCycler480 II (Roche) No Extracted RNA!
RT-PCR instrument (not defined) 5 channels
PrimerDesign-Novacyt required No Extracted RNA!
Extraction & PCR set-
Genetic Signatures BioRad CFX, QuantStudio 5 or 7 up GS1-HT or GSmini GS-1 or GSmini
Randox Investigator,
X2 theremoshaker,
Randox Standard block PCR (not RT-assay) carrier-holders off board
Genefirst SLAN 96P, BioRad CFX96 No off board
BGI ABI7500 No off board
Commecrially
available extractions
systems - long list of
Elitech Group RT-PCR instrument (not defined) 5 channels No inclusions
Qiagen QIAstat-Dx Analyser on-board QIAstat
ABI7500-FAST, ABIStep-One, BioRad CFX96,
AgilentAriaMx,DNA-Technology DT-Prime,Dtlite,
Rotor-Gene-Q, Cepheid SmartCycler, Roche
Pro-Lab-Certest Cobasz480, VIASURE 48 or 96 RTPCR system. No off-board
Shanghai ZJ Bio-tech_ ABI 7500/7900, BioRadCFX98, RotorGene
Liferiver 6000, SLAN-96, MIC POC Dx48 No off-board
StepOne, StepOne-plus, BI 7500 Fast,
Genetic PCR LightCycler Nano, BioRad CFX96, PikoReal
Solns_Bioconnections 24well, MiniOpticon 48-12, OptiCon 2. No off board
Diagnostics for the Real SAMBA II platform,
World N/A Tablet, Printer N/A
GenMark e-plex e-Plex
Not yet
to
Cepheid GeneXpert GeneXpert market
Not yet
to
bioMerieux Biofire Biofire, PCR RUO market
Hologic Panther Fusion No

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Appendix 9: Health and Safety Guidance

HS002G Guidance for

samples suspected of containing high haz agts_v1.00.pdf

RA07238_Template
Assessment HG3 SARS-CoV-2.pdf

Appendix 2_Checklist
to support risk assessments for work with suspected high hazard samples.docx

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